## Abstract

Background

International travel to developing countries is increasing with rising levels of disposable income; this trend is seen in both adults and children. Risk‐taking attitude is fundamental to research on the prevention of risky health behaviors, which can be an indicator of the likelihood of experiencing illness or injury during travel. The aim of this study is to investigate whether risk‐taking attitudes of youths are associated with travel characteristics and likelihood of experiencing illness or injury while traveling to nonindustrialized countries.

Methods

Data were analyzed from the 2008 YouthStyles survey, an annual mail survey gathering demographics and health knowledge, attitudes, and practices of individuals from 9 through 18 years of age. Travelers were defined as respondents who reported traveling in the last 12 months to a destination other than the United States, Canada, Europe, Japan, Australia, or New Zealand. Risk‐taking attitude was measured by using a four‐item Brief Sensation‐Seeking Scale. All p values ≤0.05 were considered significant.

Results

Of 1,704 respondents, 131 (7.7%) traveled in the last 12 months. Females and those with higher household income were more likely to travel (odds ratio = 1.6,1.1). Of those who traveled, 16.7% reported seeking pretravel medical care, with most visiting a family doctor for that care (84.0%). However, one‐fifth of respondents reported illness and injury during travel; of these, 83.3% traveled with their parents. Males and older youths had higher mean sensation‐seeking scores. Further, travelers had a higher mean sensation‐seeking score than nontravelers. Those who did not seek pretravel medical care also had higher mean sensation‐seeking scores (p = 0.1, not significant).

Conclusions

Our results show an association between risk‐taking attitudes and youth travel behavior. However, adult supervision during travel and parental directives prior to travel should be taken into consideration. Communication messages should emphasize the importance of pretravel advice, target parents of children who are traveling, and be communicated through family doctors.

The arrivals of international tourists grew from 25 to 903 million worldwide between 1950 to 2007, and are expected by 2010 to reach 1 billion. 1 In 2007, approximately 31 million US residents traveled to an overseas destination for different travel reasons. 2 This trend is not only seen in adults, but also in youths as well. American students are increasingly participating in study‐abroad programs to unconventional destinations, with strong increases in students going to China, India, South Africa, Argentina, and Ecuador. 3

Though still largely occurring in industrialized countries, international travel has shown fast growth in developing economies in Asia, Central and Eastern Europe, Middle East, Southern Africa, and South America. 1 Travel to developing destinations presents different health risks and is found to be associated with the likelihood of diagnoses of certain diseases. 4 In a study of those who traveled to a developing destination, 64% reported an illness after returning. 5

Recommendations for staying healthy during travel include learning about the destination, seeking pretravel medical care, and obtaining the appropriate medications and vaccinations. 6 In addition, risk perception is increasingly being recognized as an important factor in disease prevention due to its relationship to willingness to take preventive measures. 7 Prior research on risk‐taking behaviors has been conducted via studies of sensation seeking, a personality trait believed to have a biological basis that is expressed as a need for physiological arousal, novel experience, and a willingness to take social, physical, and financial risks to obtain such stimulation. 8 Sensation seeking is fundamental to research on the prevention of risky health behaviors and has been shown to be associated with a variety of behaviors, including taking physical risks, illegal drug use, and reckless driving. 8,9 Risk‐taking attitudes and risk perceptions of travel‐related illnesses and injuries can be indicators of the likelihood of engaging in risk behaviors and subsequently the likelihood of experiencing illness during or after travel.

The few studies that have examined the relationship between risk‐taking attitudes and travel have focused primarily on risk perceptions of older age groups. In a study of Hong Kong Chinese, younger travelers (15–24 y) who regarded their future trips to be at low risk were relatively more likely to have developed health problems. 10 In addition, Aro and colleagues found that during the avian influenza outbreak younger Finnish travelers (<40 y) and those on holidays were willing to take more travel‐related health risks than those who were older and on business trips. 11 The aim of this study is to investigate whether risk‐taking attitudes of youths (9–18 y) are associated with travel characteristics and likelihood of experiencing illness or injury while traveling to nonindustrialized countries.

## Methods

Data were analyzed from the 2008 YouthStyles survey, an annual mail survey gathering health knowledge, attitudes, and practices of persons 9 through 18 years of age. These are based on the results of a series of consumer mail panel surveys administered in several waves. The mail panel consists of approximately 340,000 potential respondents who are recruited to join through a four‐page questionnaire. Stratified random sampling of the mail panel was used to generate a list of 20,000 potential respondents for the ConsumerStyles survey, which was the first wave and was stratified on region, household income, population density, age, and household size to create a nationally representative sample. Additionally, a low‐income/minority supplement (N = 3,000) was used to ensure adequate representation of those groups, and households‐with‐children supplement (N = 6,000) was used to ensure adequate numbers of potential respondents for the second wave, YouthStyles. In 2008, the ConsumerStyles survey was completed by 10,108 people, yielding a response rate of 50.5%. The YouthStyles survey was a follow‐up survey sent to households that returned the ConsumerStyles survey, and was intended for the parents, children, and adolescents in each household. It was mailed to 2,605 households; 1,704 responses were received, yielding a 65.4% response rate. A small incentive (monetary value less than $5) was given if the survey was completed and returned by August 2008. Youthstyles data were weighted to reflect age and sex of child, household size, household income, head of household age, and race/ethnicity of adult of the US population, as determined by the 2007 Census estimates taken from the Current Population Survey. A traveler to a nonindustrialized country (from now on referred to as “traveler”) was defined as a respondent who reported traveling in the last 12 months to a destination other than the United States, Canada, Europe, Japan, Australia, or New Zealand. ### Risk‐taking Attitudes Measure Risk‐taking attitude was measured by using a four‐item Brief Sensation‐Seeking Scale (BSSS‐4) derived from the BSSS. 8 The four items of the BSSS‐4 are designed to assess four previously identified factors that comprise the construct of sensation seeking: experience seeking, disinhibition, thrill and adventure seeking, and boredom susceptibility. The four items (questions 8–11, Table 1) of the BSSS‐4 were scored continuously (1–4), providing a total sensation‐seeking score ranging from 4 to 16. Table 1 YouthStyles, 2008, survey questions analyzed Question Response In the last 12 months, have you traveled outside the United States on a trip lasting more than 1 d to anywhere other than Canada, Europe, Japan, Australia, or New Zealand? Yes, no 2* Where did you go? Mexico, Africa, Caribbean, Middle East, Central/South America, Oceania/Pacific Islands, India, other countries in Asia 3* Before you traveled to these countries, did you go to any of the following places for pretravel medical care? Family doctor, pharmacist, health department, travel clinic, other, none 4* Before you traveled to these countries, did you receive any of the following? Hepatitis A vaccine, antimalaria pills, yellow fever vaccine, antidiarrhea pills, typhoid vaccine, meningitis vaccine, none, don't know Did you travel to any of these countries without your parents? Yes, no 6* Why did you (your parents) travel to these countries? Vacation, medical care, visiting friends or relatives, parent's business trip, research/student, volunteer/missionary, adoption, other 7* Did any of the following things happen to you or your parents while you were traveling to these countries? Diarrhea, fever, injury due to motorized vehicle accident, cough/cold/pneumonia, other injury, other illness, none I like doing scary things. Really disagree, sort of disagree, sort of agree, really agree I like new and exciting experiences, even if I have to break the rules. Really disagree, sort of disagree, sort of agree, really agree 10 I would like to explore strange places. Really disagree, sort of disagree, sort of agree, really agree 11 I prefer friends who are exciting and unpredictable. Really disagree, sort of disagree, sort of agree, really agree Question Response In the last 12 months, have you traveled outside the United States on a trip lasting more than 1 d to anywhere other than Canada, Europe, Japan, Australia, or New Zealand? Yes, no 2* Where did you go? Mexico, Africa, Caribbean, Middle East, Central/South America, Oceania/Pacific Islands, India, other countries in Asia 3* Before you traveled to these countries, did you go to any of the following places for pretravel medical care? Family doctor, pharmacist, health department, travel clinic, other, none 4* Before you traveled to these countries, did you receive any of the following? Hepatitis A vaccine, antimalaria pills, yellow fever vaccine, antidiarrhea pills, typhoid vaccine, meningitis vaccine, none, don't know Did you travel to any of these countries without your parents? Yes, no 6* Why did you (your parents) travel to these countries? Vacation, medical care, visiting friends or relatives, parent's business trip, research/student, volunteer/missionary, adoption, other 7* Did any of the following things happen to you or your parents while you were traveling to these countries? Diarrhea, fever, injury due to motorized vehicle accident, cough/cold/pneumonia, other injury, other illness, none I like doing scary things. Really disagree, sort of disagree, sort of agree, really agree I like new and exciting experiences, even if I have to break the rules. Really disagree, sort of disagree, sort of agree, really agree 10 I would like to explore strange places. Really disagree, sort of disagree, sort of agree, really agree 11 I prefer friends who are exciting and unpredictable. Really disagree, sort of disagree, sort of agree, really agree *Multiple responses possible. ### Statistical Analyses Descriptive statistics of frequencies and percentages were analyzed. Fisher's exact test was used for categorical variables, while Wilcoxon rank‐sum test was used for continuous variables. p Values ≤0.05 were considered significant. Bivariate and multivariate logistic regressions were done to calculate odds ratios and 95% confidence intervals for demographic characteristics, with the final multivariate model determined using backwards elimination at a 5% significance level for variable selection. Cronbach's coefficient alpha was used to determine internal consistency reliability for the four subscale survey questions. All analyses were done by using SAS software (Version 9.2; SAS Institute, Cary, NC, USA). ## Results ### Demographics and Travel Characteristics Of the 1,704 respondents, 131 (7.7%) had traveled in the previous 12 months to a nonindustrialized country. The mean age of travelers was 14 years old, and 59% of those who traveled were female (Table 2). Females were more likely to travel than males (p = 0.01). Compared with other variables, travel was also more positively associated with increasing household income (p < 0.0001), marital status of parents (p = 0.007), and increasing household size (p = 0.03). The multivariate model showed that the only significant factors associated with travel were sex (p = 0.01) and household income (p < 0.0001) (Table 2). Table 2 Frequency of demographic characteristics of traveler* versus nontraveler among 9‐ to 18‐year olds, United States, 2008, YouthStyles (N = 1,704) Traveler (n = 131) n (%) Nontraveler (n = 1573) n (%) Bivariate logistic regression OR (95% CI) Multivariate logistic regression OR (95% CI) Sex Male 53 (41) 808 (52) 1.59 (1.11–2.28) 1.61 (1.12–2.32) Female 78 (59) 741 (48) Age Mean 14.0 13.5 9–13 y 56 (43) 762 (49) 1.05 (0.99–1.12) 14–18 y 75 (57) 786 (51) Marital status of parents Married 114 (87) 1182 (76) 0.49 (0.29–0.82) Other 17 (13) 366 (24) Household size 2 to 4 87 (67) 1,065 (69) 1.16 (1.01–1.32) 5 or more 44 (33) 483 (31) Household income Under$60,000 47 (36) 766 (49) 1.09 (1.05–1.14) 1.10 (1.05–1.15)
$60,000 or more 84 (64) 782 (51) Traveler (n = 131) n (%) Nontraveler (n = 1573) n (%) Bivariate logistic regression OR (95% CI) Multivariate logistic regression OR (95% CI) Sex Male 53 (41) 808 (52) 1.59 (1.11–2.28) 1.61 (1.12–2.32) Female 78 (59) 741 (48) Age Mean 14.0 13.5 9–13 y 56 (43) 762 (49) 1.05 (0.99–1.12) 14–18 y 75 (57) 786 (51) Marital status of parents Married 114 (87) 1182 (76) 0.49 (0.29–0.82) Other 17 (13) 366 (24) Household size 2 to 4 87 (67) 1,065 (69) 1.16 (1.01–1.32) 5 or more 44 (33) 483 (31) Household income Under$60,000 47 (36) 766 (49) 1.09 (1.05–1.14) 1.10 (1.05–1.15)
$60,000 or more 84 (64) 782 (51) *All travel refers to nonindustrialized countries. Reference group. Ordinal variable. The regions most often visited were Mexico (44.3%), the Caribbean (42.4%), and Central/South America (12%). The majority traveled for vacation (81.0%), followed by visiting friends or relatives (21.7%) and research/student (5.8%). Nearly one fifth of youth travelers (18.0%) traveled without their parents (Table 3). Those who traveled without parents were more likely to be older than respondents who traveled with their parents (p = 0.001), with the mean age of those who traveled alone being 15.5 and those who traveled with parents being 13.5 years. Among respondents who traveled without their parents, vacation (62%) and research/student (20%) were the most frequent travel reasons. Table 3 Frequency of reported travel* characteristics among 9‐ to 18‐year olds, United States, 2008, YouthStyles (N = 131) n (%) Destination region (n = 145 Mexico 58 (44) Caribbean 56 (42) Central/South America 12 (9) Other 19 (15) Travel reason (n = 161 Vacation 106 (81) Visiting friends and relatives 28 (22) Research/student 8 (6) Other 19 (15) Pretravel medical care (n = 131) 25 (19) Medicine/vaccine usage (n = 139 None 83 (64) Don't know 29 (22) Received one or more§ prior to trip 27 (21) Traveled without parents (n = 131) 24 (18) Illness/injury during travel (n = 131) 26 (20) n (%) Destination region (n = 145 Mexico 58 (44) Caribbean 56 (42) Central/South America 12 (9) Other 19 (15) Travel reason (n = 161 Vacation 106 (81) Visiting friends and relatives 28 (22) Research/student 8 (6) Other 19 (15) Pretravel medical care (n = 131) 25 (19) Medicine/vaccine usage (n = 139 None 83 (64) Don't know 29 (22) Received one or more§ prior to trip 27 (21) Traveled without parents (n = 131) 24 (18) Illness/injury during travel (n = 131) 26 (20) *All travel refers to nonindustrialized countries. Multiple responses possible. Received pretravel medical care from at least one of these: family doctor, pharmacist, health department, travel clinic (see question 3, Table 1). §Hepatitis A vaccine, antimalaria pills, yellow fever vaccine, antidiarrhea pills, typhoid vaccine, meningitis vaccine (see question 4, Table 1). Experienced at least one of these: diarrhea, fever, injury due to motorized vehicle accident, cough/cold/pneumonia, other injury, other illness (see question 7, Table 1). ### Pretravel Medical Care Of the respondents who traveled, only 19.0% reported seeking pretravel medical care from at least one of the following: family doctor, pharmacist, health department, travel clinic, or other. Of those who sought pretravel medical care, the family doctor was the most common source of receiving that care (84.0%). Approximately two thirds (63.7%) reported not receiving any of the following: hepatitis A vaccine, antimalaria prophylaxis, yellow fever vaccine, antidiarrhea prophylaxis, typhoid vaccine, or meningitis vaccine. Approximately one fifth of respondents (21.9%) did not know whether they had received any pretravel vaccines (Table 3). ### Illness or Injury During Travel One fifth of the respondents (20%) reported experiencing one of the following during travel: diarrhea, fever, injury due to motorized vehicle accident, cough/cold/pneumonia, other injury, or other illness (Table 3). Almost all (83.3%) of the respondents who reported illness or injury during travel had traveled with their parents. ### Risk‐Taking Attitudes The four items of the BSSS‐4 showed acceptable internal consistency and reliability (Cronbach's alpha = 0.7). Males had higher sensation‐seeking scores than females (p = 0.0008), and older youths had higher sensation‐seeking scores than younger youths (p < 0.0001) (Table 4). Table 4 Total sensation‐seeking score (4–16) comparisons between groups among 9‐ to 18‐year olds, United States, 2008, YouthStyles (N = 1,704) n Mean Wilcoxon Rank Sum p value Sex Male 861 10.14 0.0008 Female 819 9.73 Marital status of parents Married 1296 9.95 0.95 Other 383 9.85 Household size 2–4 1152 10.02 0.06 5 or more 527 9.71 Household income Under$60,000 813 9.76 0.05
$60,000 or more 866 10.07 Age 9–13 y 818 9.58 <0.0001 14–18 y 861 10.25 Pretravel care Yes 25 9.87 0.1 No 106 10.78 Traveled Yes 131 10.58 0.02 No 1573 9.87 Traveled without parents Yes 24 10.99 0.4 No 107 10.50 Illness/injury during travel Yes 26 10.53 0.4 No 105 10.84 n Mean Wilcoxon Rank Sum p value Sex Male 861 10.14 0.0008 Female 819 9.73 Marital status of parents Married 1296 9.95 0.95 Other 383 9.85 Household size 2–4 1152 10.02 0.06 5 or more 527 9.71 Household income Under$60,000 813 9.76 0.05
$60,000 or more 866 10.07 Age 9–13 y 818 9.58 <0.0001 14–18 y 861 10.25 Pretravel care Yes 25 9.87 0.1 No 106 10.78 Traveled Yes 131 10.58 0.02 No 1573 9.87 Traveled without parents Yes 24 10.99 0.4 No 107 10.50 Illness/injury during travel Yes 26 10.53 0.4 No 105 10.84 Respondents who traveled had a higher mean sensation‐seeking score than those who did not travel (p = 0.02). Although not significant, respondents who did not seek pretravel medical care had higher sensation‐seeking scores than respondents who did (p = 0.1). Furthermore, among respondents who traveled, we found no significant associations between the individual sensation‐seeking factors and whether they traveled without their parents or experienced illness or injury during travel (Table 4). ## Discussion The most frequent travel destinations among youth travelers in the YouthStyles survey were locations closest to the United States, which is consistent with the top regions of destination (excluding Europe) for US resident adult travelers in 2007. 2 Those who were older were more likely to travel without their parents, as older age tends to be associated with less parental supervision and a higher likelihood of traveling for reasons such as study or research. Of those who traveled alone, 20% traveled for student and research opportunities. Higher household income was also associated with travel to nonindustrialized destinations, possibly because travel is more accessible if there is the income to afford it. 1 Only 19.0% of respondents in this study traveled reported‐seeking pretravel medical care, with the majority seeing a family doctor to receive that care. In contrast, 36% of adult travelers from the United States sought travel health advice. 12 These data corroborate a previous finding that children were less likely than adults to have received pretravel medical advice. 13 Before traveling, approximately two thirds of travelers (63.7%) reported not receiving any of the listed medications or vaccinations. Failing to obtain pretravel vaccinations could be influenced by a variety of factors related to the knowledge, attitudes, and beliefs of the traveler regarding travel vaccines and vaccine‐preventable diseases, 14 but because the destination information in this study was by region and not by a specific city or country, it was difficult to determine whether medication or vaccination was appropriately received. Approximately one fifth (21.9%) of youth travelers did not know whether they had received any of the listed vaccines or medications. These findings are consistent with the results reported by Hartjes and colleagues 15 that 58% of study abroad students reported not receiving travel vaccinations. ### Risk‐Taking Attitudes In this study, we found that youths who traveled to nonindustrialized destinations had higher sensation‐seeking scores than those who did not. Additional evidence for the validity of the BSSS‐4 was provided by the fact that, consistent with earlier studies of sensation seeking, 8,16 males had higher sensation‐seeking scores than females, and older youths had higher sensation‐seeking scores than younger youths. Those with a household income of$60,000 or more also had a higher mean sensation‐seeking score.

Although not significantly different, the finding that youth travelers who did not seek pretravel medical care had higher mean sensation‐seeking scores than those travelers who did is suggestive. This difference could possibly be significant if this study were replicated in a larger sample. However, young travelers' decisions whether to seek pretravel medical care are likely to be determined by multiple factors such as their parents' directive (or program directive, in the case of study and/or research), and not solely a result of their sensation‐seeking score. Similarly, youths' decision to travel is also often dependent upon parental travel plans and permission. Furthermore, those who reported illness/injury during travel had a lower mean sensation‐seeking score than those who did not report illness/injury, though also not significantly different. This could be a result of the survey question, which asked about illness/injury occurring to either the child or the parent, whereas the sensation‐seeking score was solely based on the child's response.

In addition, approximately 7% of US adult residents indicated they traveled with children in 2007, with an average travel party size of 1.5. 2 A study of 15–18 year olds indicated that illness and injury are common in those traveling to nonindustrialized countries, even under adult supervision. 17 Other studies have also shown that travelers visiting friends and relatives (VFRs) are more likely to travel with children, staying in places with suboptimal sanitation and greater malaria risk, and more likely to make last‐minute travel plans, allowing little time to receive pretravel medical care. 18 With over 80% of our study population traveling with their parents to nonindustrialized countries and 20% reporting having experienced illness or injury during travel, it seems of interest to study the adults who travel with children and whether their risk‐taking attitudes are associated with seeking pretravel advice prior to their trip and how that affects the younger children who travel with them.

### Limitations

There are several limitations to this study. First, the size of the studied sample did not allow for in‐depth investigation into further associations between travel reasons, travel without parents, illness/injury experienced during travel, travel vaccines/medicines, and destination region in relation to risk‐taking attitudes. Second, because the vaccination data are self‐reported information, accuracy cannot be confirmed. However, some studies have suggested that as many as 25% of patients who report receiving immunizations may actually not have received them. 19 Finally, participation in the survey was voluntary and was not mailed more than once to increase the response rate nor the results previously validated, indicating that respondents might have different demographic characteristics and travel behavior from nonrespondents, and might not be representative of the general US population. Recall bias and sensitivity to some items may also be reflected in the responses.

## Conclusions

This study provides exploratory findings in areas where little research has been conducted. Females and those who have a higher household income were more likely to travel, and one fifth of respondents reported experiencing illness or injury during travel. Those who traveled to a nonindustrialized country had a higher mean sensation‐seeking score than those who did not, and although not significantly different, those who did not seek pretravel medical care also had a higher mean sensation‐seeking score, showing a suggestive link regarding youth travel behavior that should be further explored in a larger study to confirm our findings. Adult supervision during travel and parental plans and directives prior to travel should be taken into consideration. Knowing that pretravel advice is a precautionary measure taken to keep travelers healthy, communication messages should be directed toward parents of children who are traveling and the importance of pretravel advice to prevent health problems. These messages should be communicated through family doctors, as they are one of the main sources where travelers seek pretravel medical care. The area of youth travel, specifically those under age 18, needs to be explored more, especially when linked with travel with or without adult supervision.

The authors thank Nina Marano, Emad Yanni, and Amanda Whatley for their assistance in survey question development, and William Pollard for his assistance with the YouthStyles database.

## Declaration of interests

The authors state they have no conflicts of interest to declare.

## Disclaimer

The findings and conclusions expressed by authors contributing to this journal do not necessarily reflect the views of the Centers for Disease Control and Prevention.

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